durable medical equipment (dme) - Blue Cross NC

1 Corporate medical Policy durable medical equipment (DME). File Name: durable_medical_equipment_(dme). Origination: 1/2000. Last CAP Review: 9/2021. Next CAP Review: 9/2022. Last Review: 9/2021. Description of Procedure or Service durable medical equipment (DME) is any equipment that provides therapeutic benefits to a patient in need because of certain medical conditions and/or illnesses. durable medical equipment (DME) consists of items which: are primarily and customarily used to serve a medical purpose;. are not useful to a person in the absence of illness or injury;. are ordered or prescribed by a physician;. are reusable ;. can stand repeated use, and are appropriate for use in the home.

2 DME includes, but is not limited to, wheelchairs (manual and electric), hospital beds, traction equipment , canes, crutches, walkers, kidney machines, ventilators, oxygen, monitors, pressure mattresses, lifts, nebulizers, bili blankets and bili lights. This medical policy discusses the following aspects of DME coverage: durable medical equipment in general Maintenance, repair and replacement Upgrade options Rental versus purchase of the equipment See also: Other medical policies for specific DME, including, but not limited to Wheelchairs, Pressure Reducing Support Surfaces, Orthotics, and Children's Mobility and Positioning equipment as this equipment is not addressed in this policy.

3 Related Policies: Wheelchairs Children's Mobility and Positioning equipment Pressure Reducing Support Surfaces **Note: This medical Policy is complex and technical. For questions concerning the technical language and/or specific clinical indications for its use, please consult your physician. Page 1 of 9. An Independent Licensee of the Blue Cross and Blue Shield Association durable medical equipment (DME). Policy BCBSNC will provide coverage for durable medical equipment when it is determined to be medically necessary because the medical criteria and guidelines for its use are met. BCBSNC will provide coverage for Repairs, Maintenance and Replacement of eligible DME.

4 When it is necessary to make the equipment usable. BCBSNC will review the option to rent or purchase eligible DME. Benefits Application This medical policy relates only to the services or supplies described herein. Please refer to the Member's Benefit Booklet for availability of benefits. Member's benefits may vary according to benefit design; therefore member benefit language should be reviewed before applying the terms of this medical policy. DME, when eligible for coverage, is covered under the durable medical equipment provision of the member benefit. The DME supplier must meet eligibility and/or credentialing requirements as defined by the Plan to be eligible for reimbursement.

5 When durable medical equipment and Services are covered durable medical equipment may be covered when All of the following criteria are met: 1. The equipment provides therapeutic benefit to a patient in need because of certain medical conditions and/or illnesses; And 2. The DME is prescribed by a provider or other professional provider; And ** See policy guideline 3. The DME does not serve primarily as a comfort or convenience item; And 4. The equipment does not have significant non- medical uses ( , environmental control equipment , air conditioners, air filters, and humidifiers). Items that do not meet the definition of DME may be covered when it is clearly established that the items serve a therapeutic purpose in an individual case.

6 To establish medical necessity for this type of item, there must be documentation of the physician's plan of treatment, predicted outcomes, and physician's involvement in supervising the use of the prescribed item. Examples include: gel pads, pressure mattresses, or water mattresses when prescribed for a patient who has decubitus ulcers (pressure sores or bedsores), or there is medical evidence indicating that there is a high susceptibility to significant decubitus ulcers. Maintenance, Repairs, and Replacement of PURCHASED DME: Maintenance, repair, or replacement and supplies are eligible for separate reimbursement under a contracted maintenance fee with a DME supplier acceptable by the Plan.

7 If the expense for repairs exceeds the estimated expense of purchasing or renting another item of equipment for the remaining period of medical need, no payment can be made for the amount in excess. The repair charge may include the use of "loaner" equipment when necessary. When equipment is purchased, coverage for a maintenance or service agreement will be subject to the terms of the provider's contracted maintenance agreement. Page 2 of 9. An Independent Licensee of the Blue Cross and Blue Shield Association durable medical equipment (DME). Replacement of a purchased item may occur when the item is irreparably damaged, or if replacement is required during repair and/or maintenance of a specific item.

8 The cost will be negotiated on a rental versus purchase agreement. Replacement may be based on the mainte- nance contract as stated above. Replacement or repair of an item that has been misused or abused by the member or member's caregiver will be the responsibility of the member. Maintenance, Repairs, and Replacement of RENTAL DME: DME rental fees will cover the cost of maintenance, repairs, replacements, adjustments, supplies, and accessories. Rental fees also include equipment delivery services and set-up, education and training for patient and family, and nursing visits; and these services are not eligible for separate reimbursement. Payment of eligible fees will begin on the day the device is delivered to our member.

9 Replacement of the rental equipment may occur when the rented item is irreparably damaged, or if replacement is required during repair and/or maintenance of a specific item. Monthly rental fees allow for the replacement costs, and are not eligible for separate reimbursement. Replacement or repair of an item that has been misused or abused by the member or member's caregiver will be the responsibility of the member. Coverage for DME Add-ons or Upgrades: Standard DME is one that will adequately meet the medical needs of the patient and is not designed or customized for a specific individual's use. Non-standard DME is any item that has certain convenience or luxury features.

10 Electrical or mechanical features which enhance standard or basic equipment usually serve a convenience function. When durable medical equipment and Services are not covered DME Add-ons or Upgrades are not covered: When the DME add-ons or upgrades are intended primarily for convenience or upgrades beyond what is necessary to meet the member's legitimate medical needs. Examples include: decorative items, unique materials ( magnesium wheelchairs wheels, lights, extra batteries, etc.)*; or When it does not provide a therapeutic benefit to a patient in need because of certain medical conditions or illnesses; or When the DME has not been prescribed by a provider or other professional provider; or ** See policy guideline When the DME serves primarily as a comfort or convenience item.